Internet Addiction Recovery Program APPLICATION ... - HEAL
Internet Addiction Recovery Program APPLICATION ... - HEAL
Internet Addiction Recovery Program APPLICATION ... - HEAL
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PARTICIPANT HISTORY (Continued)<br />
TRAUMA HISTORY (Check all that apply)<br />
<strong>Internet</strong> <strong>Addiction</strong> <strong>Recovery</strong> <strong>Program</strong><br />
Anxious Hyper vigilant Nightmares Sleeplessness Phobias<br />
Prefers Isolation Depressed Shy/Withdrawn Dissociates Avoidant<br />
Headaches Stomachaches Under eating Over eating Binge eating<br />
Conduct Problems Peer problems Irritable/Angry Bullying Hyperactivity<br />
Low impulse control Violent behavior Running Away Lying Stealing<br />
Sexually acting out Low Self‐Esteem Lacks Empathy Distracted Homicidal Thoughts<br />
Participant is a survivor of<br />
Sexual assault Physical abuse Verbal abuse Emotional/Psychological Abuse Car Accident War/Veteran<br />
Serious Illness/Disability Divorce Multiple Relocations Loss of Home Natural Disaster Death in the Family<br />
<br />
<br />
Past history of suicide attempts Please describe ________________________________________________________ How many ___________<br />
Does participant report feeling hopeless ___________________________________________________________________________________<br />
STRESS<br />
List the types of stresses participant experiences (family, work, relationship, self, health etc.)<br />
____________________________________________________________________________________________________________<br />
____________________________________________________________________________________________________________<br />
How does participant handle stress ______________________________________________________________________________<br />
LEGAL HISTORY<br />
Is there a history of legal trouble If so, please describe _________________________________________________________________________<br />
Has there been an arrest If so, for what ____________________________________________________________________________________<br />
Participant is on probation. If so, what are the requirements _____________________________________________________________________<br />
Have any other family members experienced legal problems If so, who and what __________________________________________________<br />
EMPLOYMENT HISTORY<br />
Participant is currently employed. Employer’s name ___________________________________________________________________________<br />
Job Title _________________________________________________ Length of employment _________________________________________<br />
Participant has been terminated from a previous job. If so, describe ______________________________________________________________<br />
RELATIONSHIPS<br />
Is participant involved in a romantic relationship Yes No Please list important people and friends in participant’s life:<br />
Name City State Phone<br />
Page | 6<br />
reSTART <strong>Internet</strong> <strong>Addiction</strong> <strong>Recovery</strong> <strong>Program</strong> | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189<br />
restart@netaddictionrecovery.com | www.netaddictionrecovery.com
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